Racial disparities exist in rates of pneumococcal polysaccharide vaccine (PPV) and influenza vaccine resulting in unprotected persons who suffer from preventable diseases and deaths. Recent research indicates that blacks and whites are largely treated by different providers and that these providers differ in (training and in resources. In order to investigate the extent to which practice-level differences contribute to racial disparities, we plan to: (1) identify strategies used by the medical practices to facilitate immunizations; (2) characterize the practices in order to understand current organization and patterns of patient care as well as critical pathways for potential change; and (3) calculate PPV and influenza vaccination rates for the various practices and, using hierarchical regression analyses, calculate the determinants of these rates. To be feasible with a high response rate, an intentional sampling of 14 practices, 7 with a high proportion of blacks and 7 with a high proportion of whites will be conducted. Practices will come from the Medical Center's diverse network and from federally qualified health centers (FQHCs). Surveys will be conducted of both clinicians and office managers about immunization strategies, practice organization, culture, and immunization, based on the Awareness-to-Adherence model. Medical record reviews will be conducted on a random sample of 165 patients per practice (2310 total) to determine immunizations, missed opportunities, continuity of care and chart organization. Analyses will be conducted using SUDAAN to account for clustered data; hierarchical linear modeling will account for multilevel (practice, clinician, & patient) data; and multinomial regression for repeat influenza vaccinations. A team of anthropologists will visit the offices to assess organization, culture, and pathways for change and to collect timing data on the length of visits. Important features of this proposal follow: 1) the multiracial, multidisciplinary team is tied to the University's Center for Minority Health and Project EXPORT; this proposal was presented to the Center's Community Advisory Board before submission; 2) the team has published studies of how practice-level and physician- level factors influence patient immunization rates; 3) inclusion of anthropologists leads to a multimodal approach to triangulate the problem from multiple perspectives; and 4) the Medical Centers' diverse network and FQHCs provide a feasible setting with high numbers of elderly blacks and elderly whites. [unreadable] [unreadable]